SOME ADVANCES IN P ERINA TA L CARE t E. J. C O E T Z E E * M.B. Ch.B., M .R .C .O .G . SEPTEMBER 1979 P H Y S I O T H E R A P Y O ne o f th e biggest ad vances in o bstetrics has been the use o f u ltra so u n d fo r im aging an d m easu rem en t o f the fetus fro m th e 6th week a fte r m e n stru a tio n u n til delivery.U ltra so u n d is so und ab ove th e au d ib le range. W e can h ear sound w hen th e freq u en cy is betw een 16 - 20 000 cycles p er second (H erz, Hz). F o r d iag nostic u ltraso u n d w o rk in o bstetrics th e freq u en cy is 2 - 3 m illio n cycles per second (m egahertz, M Hz). B efore w e can accept this new m o d ality w e m ust, how ever, b e su re o f its safety. M any w o rk ers h ave confirm ed th a t intensities used in d ia g n o stic w o rk are safe as f a r as know n c rite ria (e.g. ch ro m osom al breaks) are concerned. In a d d itio n th e beam o f u ltraso u n d is pulsed. A pulse o f energy lasts a p p ro x im ate ly 1 m ic ro ­ second an d such pulses a re on ly rep e ated 600 - 1 000 limes p e r second. I t can, th e re fo re , be seen th a t du rin g th e v a st m a jo rity o f tim e th e re is no energy o u tp u t fro m th e m achine. I t w o uld seem th a t u n lik e X -rays, ultraso u n d can be used rep eated ly in pregnancy. FE T A L H E A D M E A SU R E M E N T O ne o f th e first fetal p a rts w h ich was clearly visualised even b y th e first m achines used was th e fetal head. Because o f this th e fe ta l h ead could b e m easured. P rofessor S. C am pbell d escribed th e s ta n d a rd techniqu e w hich should b e used w hen m easu rin g th e b ip a rie ta l diam eter (the distan ce betw een th e p a rie ta l em inences). T h ere w ere tw o im p o rta n t develop m ents fro m this work. A n ac cu rate b ip a rie ta l d ia m eter could b e equated to a g estatio n al age, especially if th e m easu rem en t was done b e fo re 28 weeks. In th e second place, th e grow th of th e fetus could b e ascertain ed by r e p e a te d . m easu re­ ments o f th e b ip a rie ta l d iam eter. U sing th is techniqu e im p o rta n t p a ra m eters o f p lacental fu n ctio n an d fetal w ell-being could be ascertained. T o d ay , w ith m ore sophisticated eq uipm ent, th e fetal h e ad circu m ference at th e level o f th e th ir d v en tricle an d th e fetal a b d o m i­ nal circu m ference at th e level o f th e u m b ilic a l vein can be m easured, ad ding im p o rta n t in fo rm a tio n concerning fetal grow th. DETEC TIO N OF A B N O R M A L IT Y W ith so p h isticated m a ch in e ry an d th e acciden tal d is­ covery th a t a fu ll b la d d er allow ed excellen t v isu alisa­ tio n o f th e pelvic organs, it becam e po ssib le to follow the g row th o f th e p regn ancy sac an d th e fetu s fro m the 6th w eek o f pregnancy. T h e fe ta l h e a rt co uld also be seen fro m a t least th e 8th week o f pregn ancy an d reco rd ed. B ecause o f this advance, th e w hole m anage­ m ent o f th rea ten ed a b o rtio n has been changed an d clinicians an d p a tien ts no long er have to w a it in sus­ pense concerning th e v ia b ility o f th e pregnancy. C on­ dition s such as a b lig h ted ovum , m issed a b o rtio n an d tro p h o b lastic disease can b e diagnosed accurately and quickly. A n o th er a p p lic a tio n ' o f diagno stic u ltra so u n d is th e accurate lo c a lisa tio n o f th e placenta in cases o f an te ­ * L ectu rer, D e p a rtm e n t o f G y n aecology an d O bstetrics, U n iv ersity o f C ape T o w n an d S en io r S pecialist, G ro o te S chuur H o spital, t P a p e r read at C ongress preceding 13th N atio n al C o uncil M eetin g 23 - 27 A p ril 1979. p a rtu m h a em orrhag e. I f th e p la cen ta is n o t lying n e a r o r over th e cervical os (placenta p rae v ia), in m any instances th e p a tie n t can b e allow ed to go hom e instead of spending th e last w eeks o f h e r preg n an cy in h ospital. T h e diagnosis o f in tra -u te rin e dem ise o f th e fetus is also possible, as is th e d e tectio n o f certain a b n o r­ m alities o f th e fetu s such as h yd ro ceph aly , anencephaly, polycystic kidneys, large cysts in th e fe ta l ab dom en, an d others. G R E Y SCALE A N D R E A L TIM E T h e newest develop m ents in u ltraso u n d a re grey scale p ictures a n d real tim e scanners. In the fo rm e r th e size o f th e reflected u ltraso u n d , an d th e re fo re o f th e electrical im pulse gen erated a t th e crystal, is re­ lated to a c e rta in sh ad e o f grey w hich gives f a r m o re d etail th a n th e p rev io u s sim ple b la ck a n d w h ite p ic­ ture. In real tim e scanning, new p ictures a re created all th e tim e an d as w ith a cine cam era m ovem ent o f th e fetus can b e seen. T h e fetu s can no w b e seen to hiccup, b reathe, m ove his lim b s an d do total bod y m ovem ents. P R E N A T A L DIA G N O SIS A second m a jo r develo p m ent is th e use o f p ren a tal diagnosis an d th e detectio n o f c e rta in fe ta l a b n o rm a li­ ties. C hrom osom al a b n o rm alitie s, as in D o w n ’s syn­ drom e, ne u ra l tu b e defects an d a h o st o f enzym e d e­ ficiency diseases can now b e detected b y p e rfo rm in g am niocentesis betw een th e 16th a n d 20th weeks. U ltr a ­ sound has p lay ed a m a jo r p a r t in m akin g a m n io ­ centesis safer. B efore inserting th e needle th ro u g h the ab d o m in a l an d u te rin e w alls in to th e am n io tic fluid, th e p o sitio n o f th e fetus an d th e p la cen ta is d eterm in ed by u ltra so u n d an d th e a p p ro p ria te sp o t is m a rk e d on th e p a tie n t’s ab do m en w here th e re will b e reasonab ly safe an d d irec t access to a m n io tic fluid. W ith th e use o f u ltraso u n d , th e p ercentag e o f failu res is reduced, the n u m b er o f needle insertions is reduced, an d clean liq u o r, u n c o n ta m in ate d w ith b lo o d , is usually o btained . I t is likely th a t th e risk o f a b o rtio n is also reduced. T h e am n io tic fluid is th e n sent to th e h u m an genetics la b o ra to ry w h ere th e alp h a-feto p ro te in is m easu red fo r detectio n o f n e u ra l tu b e defects, such as sp in a bifida an d anencephaly. T h e re a r e also viable fetal cells in th is am n io tic fluid w hich, b y carefu l techniques, can b e induced to m u ltip ly; ch rom osom al studies can be d o n e o n th e cu ltu red cells. T h e best know n an d com m onest ch rom osom al ab n o rm a lity is D o w n ’s syn­ drom e, in w h ich th e re are 3 chrom osom es in th e 21 ch rom osom e set (trisom y-21). O th er ra re r chrom osom al a b n o rm alitie s can also b e detected. T h e incidence o f D o w n ’s syndrom e increases w ith m a te rn a l age, an d a t th e m a te rn a l age o f 40 ap p ro x im ate ly 1 in 50 p reg ­ nancies could resu lt in D o w n ’s syndrom e. B efore offer­ ing p re n a ta l diagno sis o ne m ust how ever consider th a t th e re is a 1% risk o f th e p a tie n t’s a b o rtin g because o f th e p rocedure. T h e chance o f detecting an ab n o rm al fetus sh o u ld th e re fo re b e a t least 1 %. U n d er S outh A frican law, a p regn ancy w ith an a b n o rm a l fetus can be term in a ted , an d th e trag e d y o f an a b n o rm a l child thus averted. In th e late m id trim e ste r an d ea rly th ir d trim ester, am niocentesis is im p o rta n t in th e m anagem ent o f co m plicated rhesu s affected pregnancies. T h e severity R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 72 F I S I O T E R A P I E SEPTEMBER 1979 o f the haem olysis in the fetus can be ascertained by m easurin g b iliru b in -lik e pigm ents in the a m n io tic fluid. But th e m ost im p o rta n t in d icatio n fo r am niocentesis is the p rev e n tio n o f re sp ira to ry disease in the n ew ­ born. L iq u o r is usually tak en by su p rap u b ic pun cture, but som etim es u n d er u ltraso u n d guidance; 1 m l liq u o r is m ixed w ith 1 ml alco hol and shaken up. T h e am o u n t o f stable b u b b le fo rm atio n tells us w h eth er the fetus has s u rfa ctan t o r not, w hich w ill p ro tec t it from re s p ira to ry distress syndrom e. F E T A L M O N IT O R IN G A fu rth e r invasion into the privacy o f the fetal w o rld has tak en place in th e la b o u r w ard. T o m ake lab o u r safer fo r m o th er an d fetus, m o n itors have been developed w hich can m o n ito r the m o th e r’s co ntraction s an d reco rd the fetal h e a rt rate continuously. T h e n o r­ m al fetal h e a rt ra te is betw een 120 an d 160 beats ncr m in u te an d th e b aselin e should be changing all the tim e. N o rm ally th e re is no relatio n sh ip betw een the fetal h e a rt an d contractions. T h e follow ing changes arc associated w ith fetal distress. A fetal h e art rate con­ tin u o u sly above 160 (tachycardia), o r a heart rate co ntinuo u sly below 120 (brady cardia), suggests distress A b sence o f baselin e v a ria b ility is an om inous sign O ften, especially n e a r delivery; the fetal heart rate will decelerate w ith the co ntraction , b u t reco ver imme­ diately. T his is due to com pressio n o f the head. H ow ­ ever, w h en th e deceleration continues a fte r the con­ tra c tio n has ended, this is a p a rtic u la rly om inous sign o f fetal distress. W hen the o b stetricia n is w o rried ab o u t the fetal h e a rt r a te p a tte rn , he w ill tak e a sam ple o f blood fro m th e fetal scalp an d estim ate its p H value. I f the p H is below 7,2 this is alm ost alw ays an absolute sign o f a fetal p roblem ; delivery sho u ld be at once expedited, usu ally by caesarean section. REPORT ON CONGRESS PROCEEDINGS IN T RO DU CTO R Y COURS E IN N E U R O D E V E L O P M E N T A L T H E R A P Y 37 m em bers attended this course. T h e lectures an d dem on stratio ns w ere given by m em bers of the South A frican N e u ro d ev elo p m en tal T h erap y A ssociation. T he first session discussed th e properties of spasticity and the problem s w hich spasticity poses to the p h y sio th era­ pist. C u rre n t m ethods o f co ntro lling spasticity were an alysed an d the und erlying philo so p hy o f n e uro dev e­ lopm ental th e ra p y was presented. T h e follow ing session fo rm u late d the role played by the p o stu ral reflex m echanism s in d eterm ining norm al m o to r developm ent. T h e d em o n stratio n w hich follow ed show ed how these p o stural reflex m echanism s can be utilized to obtain specific m ov em ent p a ttern s in p re p a ra tio n fo r fu tu re skills as well as fu n ctio n al sequences o f m ovem ent. T h e second h a lf o f the course was devoted to an alysing th e f u n c tio n a l. pro blem s en co u n tered with sitting standing an d w alking in different types of spastic patients. T his section included an outlin e of how these problem s develop as well as guidelines fo r treatm ent. T h e w o rk sho p o n u p p er ex trem ity function was not held as p la n n ed owing to lack o f su p p o rt from Society m em bers. In stead , an in fo rm al w orksho p was thrown open to o ccupational, speech an d physical th e r a p is ts __ an d also teach ers — an d over 30 p e o p le attended two sep ara te sessions, the first devoted to analysing upper ex trem ity functions in th e n o rm a l as well as in spastic an d ath eto id ch ild re n an d the second to discussing how to establish these functions in spastic ch ildren and in ath eto id children. S. Irw in-C arruthers WORKSHOP ON C L I N I C A L SUPERVISION T h e first session o f th e w o rk sho p w hich was ch aired by M rs. A. M athias, C h ief P h y sioth erapist o f th e J o h a n ­ nesburg H o sp ita l com plex, com m enced w ith g roup fo r­ m ulation of aim s an d objectives of clinical'^supervision. T he m ost im p o rta n t aspect th a t em erged fro m these groups was realisatio n th a t th e clinical situ atio n was th e prim e area fo r g ro w th an d developm ent of th e stu ­ dent. By providing the right clim ate in the clinical situation, the student will be stim ulated to th in k independently, to use h e r initiative an d w ant to p ro b e fu rth e r an d be respon sible f o r h e r ow n learning. By teaching th roug h de m onstratio n, th e sup ervisor will encourag e acceptable standard s o f in te rp e rso n al relationships an d professional values as well as rein fo rce in practice th a t w hich is tau ght in the classroom . I n tw o very co m petent talks given by students fro m th e U niversities o f C ap e T ow n an d Stellenbosch, the need fo r b e tte r co m m unication betw een studen t an d supervisor was stressed. C laire Joh nson urged far grea ter involvem ent of the supervisor in the clinical situ a tio n an d felt th a t the student w ould o nly be able to learn, if she knew w h at was done correctly, w hat was unacceptable an d how this could be changed. C arin H u g o urged grea ter co m m itm ent on the p a rt o f the superviso r to prov id e assistance in a ll aspects o f p atien t handling by dem o n stratio n an d discussion, especially w hen the stu den t is a t the beginning o f her clinical training . T h e studen t has the right to know w h at is goo d o r bad in h er p a tie n t m anagem ent and m ust be given th e chance to co rrect m istakes as well as specify h er ow n problem s. E valuation must be objective an d th o ro u g h an d n o t be just a mark. S h a p lead ed fo r supervisors to be en thusiastic ab o u t th e il p rofession in o rd er to stim ulate the students. I n atte m p tin g to provide a m eaning ful learning e x p erien ce in th e clinical field, certain objectives for clinical supervisors w ere suggested by J. C. Beenhakker. T hese w ere teaching by d e m o n stratio n in all areas of clinical com petencies, co -ordin ating class teaching and clinical practice, setting goals fo r achievem ent in that p a rtic u la r d ep artm en t, developing skills of problem ­ solving an d provid in g co nstant an d constructive feed­ back to th e student. T his feed b ack to the student is to poin t o u t w here h e r strengths an d w eaknesses lie and w h eth er th e stu d en t has fulfilled th e stated goals. The stu d en t sh o u ld also be en courag ed to assess the super­ viso r jn o rd e r to bring ab o u t desirable change. The ideal superviso r should be com petent in he r own field, be available a t all tim es, be ab le to com m unicate with th e stu d en t an d be sensitive to h er needs. I n th e second session u n d e r th e C hairm an sh ip of Miss M. J. R un nalls, H e ad o f the D epartm en t of P h y sio th erap y o f th e U niversity o f Stellenbosch and Tygerberg- H o spital, th e em phasis was on the methods by w hich clinical supervision should be carried out. A lth o u g h P. B ow erbank, C h ief P hy sioth erapist at K a lafo n g H o spital, presen ted h er talk in the form of a R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )